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DS 11 From 2004
DS 11 From 2004
Department of State
APPLICATION FOR A US PASSPORT
PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS.
I applied: Place:
Date:
FOR INFORMATION, QUESTIONS, AND INQUIRIES: Please visit our website at travel.state.gov. In
addition, contact the National Passport Information Center (NPIC) toll-free at 1-877-487-2778 (TDD:
1-888-874-7793) or by e-mail at NPIC@state.gov. Customer Service Representatives are available M-F,
8AM-8PM EST (excluding federal holidays). Automated information is available 24/7.
U.S. PASSPORTS ARE ISSUED ONLY TO U.S. CITIZENS OR NATIONALS. EACH PERSON MUST OBTAIN HIS OR HER OWN PASSPORT.
AS DIRECTED BY PUBLIC LAW 106-119 AND 22 CFR 51.27 EFFECTIVE JULY 2,2001:
To submit an application for a child under age 14 both parents or the child's legal guardian(s) must appear and
present all of the following:
Evidence of the child's US citizenship,
Evidence of the child's relationship to parents/guardian(s), AND
Parental identification.
IF ONLY ONE PARENT APPEARS YOU MUST ALSO SUBMIT ONE OF THE FOLLOWING:
Second parent's notarized written statement consenting to passport issuance for the child,
Primary evidence of sole authority to apply, OR
A written statement (made under penalty of perjury) explaining the second parent's unavailability.
See Instruction Page 2 for detailed information on the completion and submission of this Form.
You may submit items such as the following containing your signature AND physical description or photograph that is a good likeness of
you: previous U.S. passport, Certificate of Naturalization, Certificate of Citizenship, driver's license (not temporary or learner's license),
or government (Federal, State, municipal) employee identification card or pass. Temporary or altered documents are not acceptable.
When necessary, we may ask you to provide additional evidence to establish your identity.
IF YOU CANNOT PROVIDE DOCUMENT EVIDENCE OF IDENTITY as stated above, you must appear with an IDENTIFYING WITNESS who
is a US citizen, non US citizen national, or permanent resident alien who has known you for at least 2 years. Your witness must prove
his or her identity and complete and sign an Affidavit of Identifying Witness (Form DS-71) before the acceptance agent. You must also
submit some identification of your own.
3. TWO RECENT, COLOR PHOTOGRAPHS
Submit two color photographs of you alone, sufficiently recent to be a good likeness of you (normally taken within the last six months),
and 2x2 inches in size. The image size measured from the bottom of your chin to the top of your head (including hair) should not be less
than 1 inch and not more than 1-3/8 inches. The photographs must be color, clear, with full front view of your face, and printed on thin
paper with plain light (white or off-white) background. They must be capable of withstanding a mounting temperature of 225 Fahrenheit
(107 Celsius). Photographs must be taken in normal street attire, without a hat, head covering, or dark glasses unless a signed statement
is submitted by the applicant verifying the item is worn daily for religious purposes or a signed doctor's statement is submitted verifying
the item is used daily for medical purposes. Photographs retouched so that your appearance is changed are unacceptable. Snapshots,
most vending machine prints, and magazine or full-length photographs are unacceptable. Digitized photos must meet the previously
stated qualifications and will be accepted for use at the discretion of Passport Services. (Visit our website for details.)
4. FEES
a. If you are 16 years of age or older: The passport processing fee is $55, the application execution fee is $30, and the security surcharge
is $12 therefore your total cost for the passport will be $97. Your passport will be valid for 10 years from the date of issue except where
limited by the Secretary of State to a shorter period. (See information below about the additional cost for expedited service.)
b. If you are 15 years of age or younger: The passport processing fee is $40, the application execution fee is $30, and the security
surcharge is $12, therefore your total cost for the passport will be $82. Your passport will be valid for 5 years from the date of issue
except where limited by the Secretary of State to a shorter period. (See information below about the additional cost for expedited
service.)
BY LAW, THE PASSPORT PROCESSING, EXECUTION, AND SECURITY FEES ARE NON-REFUNDABLE.
The passport processing, execution, and security fees may be paid in one of the following forms: Checks (personal, certified, traveler's);
major credit card (Visa, Master Card, American Express, and Discover); bank draft or cashier's check; money order (U.S. Postal,
international, currency exchange), or if abroad, the foreign currency equivalent; or a check drawn on a U.S. bank. All fees should be
payable to the "U.S. Department of State", or if abroad, the appropriate U.S. embassy or consulate. When applying at a designated
acceptance facility, the $30 execution fee should be made payable to the acceptance facility. NOTE: Some designated acceptance
facilities do not accept credit cards as a form of payment.
For faster processing, you may request expedited service. Expedited requests will be processed in three workdays from receipt at a
passport agency. The additional fee for expedited service is $60. Therefore, if you choose to request expedited service and you are 16
years of age or older the total cost of your US passport will be $157 and if you are 15 years of age or younger the total cost of your US
passport will be $142. Expedited service is available only in the United States.
If you desire SPECIAL POSTAGE SERVICE (overnight mail, special delivery, etc.), include the appropriate postage fee with your payment.
An additional $60 fee will be charged when, upon your request, the U.S. Department of State verifies issuance of a previous U.S.
passport or Consular Report of Birth Abroad because you are unable to submit evidence of U.S. citizenship.
For applicants with US Government or military authorization for no-fee passports, no fees are charged, except the execution fee when
applying at a designated acceptance facility.
If you choose to provide your e-mail address in Item #12 on this application, Passport Services will only use that information to contract
you in the event there is a problem with your application or if you need to provide additional information to us.
DS-11 Instruction Page 2 of 4
FEDERAL TAX LAW
Section 6039E of the Internal Revenue Code (26 USC 6039E) requires you to provide your Social Security
Number (SSN), if you have one, when you apply for a US passport or renewal of a US passport. If you have not
been issued a SSN, enter zeros in box #5 of this form. If you are residing abroad, you must also provide the
name of the foreign country in which you are residing. The U.S. Department of State must provide your SSN and
foreign residence information to the Department of Treasury. If you fail to provide the information, you are
subject to a $500 penalty enforced by the IRS. All questions on this matter should be directed to the nearest IRS
office.
NOTICE TO CUSTOMERS MAKING PAYMENT BY CHECK
If you send us a check, it will be converted into an electronic funds transfer (EFT). This means we will copy your
check and use the account information on it to electronically debit your account for the amount of the check.
The debit from your account will usually occur within 24 hours, and will be shown on your regular account
statement.
You will not receive your original check back. We will destroy your original check, but we will keep the copy of
it. If the EFT cannot be processed for technical reasons, you authorize us to process the copy in place of your
original check. If the EFT cannot be completed because of insufficient funds, we may try to make the transfer up
to two times and we will charge you a one-time fee of $25, which we will also collect by EFT.
PAYMENT OF FEES
31 USC 7701 requires persons "doing business" with a federal agency to provide their social security numbers to
that agency. Because the U.S. Department of State collects fee for the provision of passport services to you,
you are considered a person "doing business" with the Department. Passport service fees are established by law
and regulation (see 22 USC 214, 22 CFR 22.1, and 22 CFR 51.61-66) and are collected at the time you apply for
the passport service. If the Department fails to receive full payment of the applicable fees, because, for example,
your check is returned for any reason or you dispute a passport fee charge to your credit card, the U.S.
Department of State will take action to collect the delinquent fees from you under 22 CFR Part 34 and the
Federal Claims Collection Standards (see 31 CFR Parts 900-904). In accordance with the Debt Collection
Improvement Act (Pub.L. 104-134), if the fees remain unpaid after 180 days and no repayment arrangements
have been made, the Department will refer the debt to the Department of Treasury for collection. Debt collection
procedures used by Treasury may include referral of the debt to private collection agencies, reporting of the debt
to credit bureaus, garnishment of private wages and administrative offset of the debt by reducing or withholding
eligible Federal payments (e.g. tax refunds, social security payments, federal retirement, etc.) by the amount of
your debt, including any interest penalties or other costs incurred.
In addition, non-payment of passport fees will result in the invalidation of your passport. An invalidated passport
cannot be used for travel.
OTHER USES OF SOCIAL SECURITY NUMBERS
In addition to reporting your Social Security Number to Treasury and using it in connection with debt collection,
the Department checks Social Security Numbers against lists of persons ineligible or potentially ineligible to
receive a US passport.
IMPORTANT NOTICE TO APPLICANTS WHO HAVE LOST OR HAD A PREVIOUS PASSPORT STOLEN
A United States citizen may not normally bear more than one valid or potentially valid U.S. passport at a time. It
therefore is necessary to submit a statement with an application for a new U.S. passport when a previous valid or
potentially valid U.S. passport cannot be presented with an application for a new passport. Your statement must
detail why the previous U.S. passport cannot be presented.
The information you provide regarding your lost or stolen U.S. passport will be placed into our Consular Lost or
Stolen Passport System. This system is designed to prevent the misuse of your lost or stolen U.S. passport.
Anyone using the passport book reported as lost or stolen may detained upon entry into the United States.
Should you locate the U.S. passport reported lost or stolen at a later time, report it as found and submit it for
cancellation. It has been invalidated. You may not use that passport for travel.
PROTECT YOURSELF AGAINST IDENTITY THEFT - REPORT YOUR LOST OR STOLEN PASSPORT!
For more information or to report your lost or stolen passport by phone, call NPIC or visit our website at
travel.state.gov.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: With the exception of your Social Security Number
(see Federal Tax Law statement on Instruction Page 3), you are not legally required to provide the information
requested on this form. However, failure to do so may result in Passport Services' refusal to accept your
application or result in the denial of a US passport.
The cover of the new passport will be printed with a special symbol representing the embedded chip. The symbol
"LOGO IMAGE" will appear in port-of-entry areas where the electronic passport can be read.
Instruction Page 4 of 4
DS-11
U.S. Department of State OMB APPROVAL NO. 1405-0004
EXPIRATION DATE: 06/30/2005
APPLICATION FOR A US PASSPORT ESTIMATED BURDEN: 85 Minutes
(See Instruction Page 3)
WARNING: False statements made knowingly and willfully in passport
applications, including affidavits or other supporting documents submitted
therewith, are punishable by fine and/or imprisonment under provisions of 18 USC
1001, and 18 USC 1542. Alteration or mutilation of a passport issued pursuant to
this application is punishable by fine and/or imprisonment under the provisions of
18 USC 1543. The use of a passport in violation of the restrictions contained
therein or of the passport regulations is punishable by fine and/or imprisonment
under 18 USC 1544. All statements and documents are subject to verification. 5 Yr. 10 Yr. Issue
Date
R D O DP
1. Name of Applicant
Last Suffix (Jr., Sr., III) End. # Exp.
M F
14. Permanent Address or Residence (If same as mailing address write "Same As Above")
2" x 2"
2" x 2"
( ) ( )
17. Have you ever applied for or been issued a If yes, complete the remaining items in block #17 and submit
YES NO
US passport? most recent passport.
Name in which your most recent passport was issued. Status of recent passport
Submitted Stolen Lost Other
Most recent passport number. Approximate date your most recent US
passport was issued or date you applied.
19. Have you ever been married? YES NO If yes, complete the remaining items in block #19
Spouse's or Former Spouse's Full Name Is your spouse (or former spouse) a U.S. citizen?
YES NO
1) 2) 3) 4)
DS-11
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03-2005
NAME OF APPLICANT (Last, First, Middle) Date of Birth (mm-dd-yyyy)
Is your mother a U.S. citizen? YES NO Is you father a U.S. citizen? YES NO
22. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency.
Name Street / RFD #
DS-11 Page 2 of 2